Tuesday, December 16, 2008

A Story From Work

I met a girl today. She's about three weeks old now, weighs about two pounds and has been in the NICU [Neonatal Intensive Care Unit] since birth. Let's call her Elizabeth - and this is her story which I feel compelled to write.

Elizabeth's mother is a crack addict with a $300 dollar per week habit. She's also an active prostitute working in the Bronx and she's got the likely slew of active infections that inevitably go along with that. Elizabeth's mother is 38 years old but looks like she's a senior citizen. Her mother realized for the first time that she was pregnant three weeks ago and came to the public hospital where I work to seek an elective termination of the pregnancy. And with a mother as unfit as she clearly is and a pregnancy as clearly unwanted as it was, nobody on staff seems to even think to object.

As you likely know, elective abortion is only legal in America up until the end of the second trimester or 24 weeks. What you may not know it that estimation of the fetal age can be done by ultrasound by taking measurements of different fetal anatomical features. It is well known by any competent obstretrics staff that by the second trimester these estimates can easily be as much as two weeks off. It can also be somewhat subjective since it depends on the ultrasound's operater to determine where to measure from. This technique's main purpose is just to show that the fetus is growing appropriately over time, not to age the fetus with a great degree of accuracy. Obviously the mother did not have even a single visit of prenatal care and so nobody knew how old the fetus was. The chief resident instructed the intern, "Go find out if the fetus is less than 24 weeks old." Then with the pressure to find a young fetus, the intern returned with a reported estimate of 23 weeks and 5 days.

With that factoid in the place, the team started to induce an abortion. The goal was to deliver the 23+ week old fetus intact and alive and then, since it being woefully premature and unprepared for the outside world, refrain from providing neonatal care with the expectation that nature would take its course and it would soon die. This is all permitted by current US law. And so this is what they did. They delivered the fetus and laid it on the crib in the delivery room under the warming light which was not turned on. She laid there for a full 7 minutes - losing body heat and not breathing while they dealt with care for the mother. At seven minutes, the attending physician walks in and sees that that fetus is still alive! She immediately calls in the neonatal pediatricians who manage to resuscitate the baby and Elizabeth is whisked away to the NICU, where she still lives today. After examination, it turns out that the baby weighed nearly 900 grams - a weight more consistent for a fetus of 27 weeks than of one of 23.

Think about what this means folks. What happened here was that these doctors were so jaded about bringing another unwanted crack-baby with hepatitis into the world that they fooled themselves (I'm being generous) into believing it was less than 24 weeks old, delivered it prematurely and then were willing to sit back and do nothing while it died right in front of them. When I saw poor Elizabeth in the NICU with tubes and probes going every which way and I heard this story I was absolutely floored. What the FUCK! I had previously worked with these people and I cannot believe that their judgement could be so absurdly screwed up on all moral, legal and medical levels.

Granted, a baby born - even at term - with a sustained cocaine exposure in utero and a number of serious infections is unlikely to have a great outcome, but delivering her prematurely and then allowing her to lie there freezing and anoxic for seven minutes surely didn't help her situation one bit! The neonatalogist treating her told me that she has good expectation to survive but zero expectation to do so without severe neurological consequences. I find it difficult to even find words to describe my enraged reaction to how the selfishness of the mother and the collaboration of her doctors lead to this horrible outcome for an innocent baby girl. It sounds like a sick joke, but she's an abortion survivor.

Of course her mom who tried to abort her did not give a damn and within one day of delivery she slipped out of the hospital and has not been heard from since. What tops the icing on this shit pie is the likelihood that if the mother had the inclination to, she probably has standing to sue for malpractice even though they were doing exactly what she asked of them and she's as, if not more so, culpable morally as any of them.

Update: 12/20/08

So I did some more sleuthing on Friday and I think I need to give those doctors an apology. Not entirely, but I think they were definitely more within their scope of practice than I had initially been told. What had actually occurred was not that the mother came in seeking an abortion, but came in with a story of abdominal pain, preterm premature rupture of membranes and likely chorioamnionitis. She hadn't wanted the pregnancy and had intended on a termination (she had had ten (TEN!) previous terminations on record) but that wasn't the reason she came in. The sono showed anhydramnios AND with their estimation of a previable fetus they decided to follow the course they did. If they hadn't induced labor then the fetus was likely to die anyway given the anhydramnios and the likely chorioamnionitis, and thereby also offer a serious risk to the mother.

What they still did wrongly though (imo), was in performing a poor estimation of the fetus' age - she was still significantly more than 24 weeks old and was indeed (obviously) viable - and then not having pediatrics in the room to perform a proper and timely resuscitation. So here it's less of a moral/legal issue and much more to do with simply poor management. All the same though, a terribly sad story all around.

"Don't people in a hospital have an obligation, absent a DNR order, to save anyone (even an crack-addicted hepatitis-infected infant) from dying?"

If a premature infant is understood to not have a significant likelihood of survival, the well established ethical course is to withhold treatment. Otherwise you'd be putting these kids through a seemingly futile agonizing few days or weeks before they finally die. That likelihood though is very different for a 22 week old as compared to a 27 week old.

Naturally though, if the parents wish to pursue aggressive treatment then their wishes are generally carried out.

The same is true for very sick adult patients. If your 98 year old septic patient with congestive heart failure and kidney disease codes for the sixth time that day, you know he must have suffered considerable trauma and you're probably reaching the brink of futility. Ethically you can just let the man pass away. Every doctor makes the call differently and it's sometimes hard to say where to draw the line.

Yes, likely so - and that's why a birth weight of some 900 grams makes their conclusions even more untenable. That's a large weight for any 24 weeker and therefore even more impressive for a fetus suspect for intrauterine growth restriction.

Bioethics is such a murky field and current medical advances make it all the more tricky. How do you reach a consensus about what constitutes a "full" human being, and who gets to decide what "quality of life" means?

I believe strongly in the sanctity of life, but this baby, born prematurely and badly damaged by her mother's lifestyle during pregnancy and the circumstances of her birth, will surely face a painful and severely compromised life. Neonatology is a noble undertaking, but sometimes, as in this case, it's clear that not every baby should be saved.

Just found your blog, and am floored by your story. I am appalled that the doctors behaved the way they did. No baby should suffer so much just because of an irresponsible mother and doctors who just don't care. Kudos to you for recognizing that, too.

"Bioethics is such a murky field and current medical advances make it all the more tricky. How do you reach a consensus about what constitutes a "full" human being, and who gets to decide what "quality of life" means?"

I completely agree. Of interest is recent legislation like the Born-Alive Infants Protection Act (2002) which states that any baby born alive - even for the purpose of an abortion - is recognized by the law as fully human in every way.

In any case, these late-term abortions are incredibly barbaric and I find it so hard to believe that people going into the medical profession could end up at a place where they'll literally snap the head off of a living 23 week old fetus in the process of an abortion - for a living. The literature shows that 23 weekers with proper prenatal amd neonatal care can have a survival rate as high as 2/3rds. Clearly something isn't adding up if Roe v. Wade made 24 weeks the limit based on the concept of viability.

"Neonatology is a noble undertaking, but sometimes, as in this case, it's clear that not every baby should be saved."

I agree with that as well. But my issue here is not with the neonatologists who were compelled to do what they could for a 900 gram baby, but with the doctors who I believe collaborated with the mother to abort a fetus who was too far along to legally (and more importantly ethically) abort. This child, by law and by right, should have stayed in the mother's womb and been delivered at term. She might have had some problems, but by far and large, she could have lived a nearly normal life.

That was indeed a terrible, powerful, story.Maybe Gianna Jessen would be someone worthwhile to talk to about it:http://hotair.com/archives/2008/09/16/video-born-alive-survivor-scolds-obama-on-vote-protecting-infanticide/

I work as a nurse in a NICU, and my heart goes out to this poor girl. Seven minutes anoxic is a HUGE amount of time and those doctors probably caused severe neurological dysfunction in addition to whatever problems her mother has already caused her. Poor kid is going to be in child protective services, if she survives. I hope she finds a loving family, and I hope that they did not cause too much damage.

"Wasn't there a huge story that Obama refused to sign into law in Chicago that if an aborted fetus is still living, doctors MUST save it. Instead, they are left to die."

I think that law actually passed in Illinois and is identical to the law passed by Congress in 2002 - the Born-Alive Infants Protection Act, as discussed above.

As far as I understand the law, it doesn't mean that doctors must make heroic efforts to save a premature or full term infant which is determined to be nonviable. The main purpose of the law, I think, seems to be that basic comfort and humane care is provided for these dying infants, rather than literally throwing them in the garbage which used to be done. Mostly though, the law just prods abortionists to make sure those fetuses are quite dead before they're fully removed from the uterus. (Which is why I mention how abortionists might literally rip the head off of a fetus during a late-term abortion.)

The woman's intention was to terminate her pregnancy. Which is her right, although one would have hoped for a much quicker decision than 24 weeks.

Then, she came seeking medical help for a situation in which her own health and well-being were at risk.

I know that you want to state things in the most shocking, most emotionally-charged terms possible, but, actually, the quick severing of the spinal cord of a vertebrate animal is generally considered to be one of the most humane ways to bring about its death. It is only our full awareness of what is happening that causes us to cringe. The fetus does not share our level of awareness, or even a thalamus-cortex connection.

Wouldn't the situation have been so much better had this quick death occurred?

"What tops the icing on this shit pie is the likelihood that if the mother had the inclination to, she probably has standing to sue for malpractice even though they were doing exactly what she asked of them . . ."

They were doing exactly what she asked of them?

I seriously doubt that the mother requested that her fetus be delivered alive, and then everybody please stand around and watch it die, perhaps to suffer. She wanted help with her own medical crisis, and, ultimately, she wanted the life of her fetus ended. How is that the same as a request for a severely premature live birth?

In spite of your efforts to paint this woman as a monster, I think we can all assume that she wanted the death of her fetus to be as quick and painless as possible.

"The woman's intention was to terminate her pregnancy. Which is her right, although one would have hoped for a much quicker decision than 24 weeks."

My point is that in all likelihood the fetus was in fact older than 24 weeks - which means she had no such right. A separate point is that 24 weeks is arbitrary and I don't think she has a "right" to even that far along.

"Wouldn't the situation have been so much better had this quick death occurred?"

Are you promoting infanticide? I don't believe doctors should be in the business of killing. Elective late term abortions are blood curdling in their horror. Ever seen one?

"I seriously doubt that the mother requested that her fetus be delivered alive, and then everybody please stand around and watch it die, perhaps to suffer. She wanted help with her own medical crisis, and, ultimately, she wanted the life of her fetus ended. How is that the same as a request for a severely premature live birth?"

On the floor she was aggressive and violent, screaming that she "wanted it out." Frankly, I don't think she cared at all about the fate of her daughter.

"In spite of your efforts to paint this woman as a monster, I think we can all assume that she wanted the death of her fetus to be as quick and painless as possible."

Assume what you wish. As a person who had had 10 (or more) previous abortions, I don't think she cared too much about her fetuses in general.

---"My point is that in all likelihood the fetus was in fact older than 24 weeks - which means she had no such right."

She didn't assign it an age. She probably had little idea how old it was. Why are you blaming her for the wrong age assessment? She's an irresponsible person, no argument. Irresponsible people, also, are entitled to clean, safe medical care.

---"On the floor she was aggressive and violent, screaming that she "wanted it out." Frankly, I don't think she cared at all about the fate of her daughter."

Perhaps she was screaming that she "wanted it out" because she was in a stressful situation and she wanted it out! Wanting it out doesn't make her evil. She is allowed to "want it out."

And, it doesn't mean that she wanted it to suffer. Or, that she wanted it to be born alive. She certainly didn't want a "daughter." She had a pregnancy. She cared about the fate of that pregnancy to the extent that she wanted it terminated. She got a live birth. A birth the result of which she knew she had zero desire, or ability, to parent.

---"Are you promoting infanticide?"

I am NOT promoting infanticide. I believe that once a living fetus separates from its mother it gains the rights of US citizenship. In the case of a living post-abortion infant, the mother has lost her total authority in determining it's fate. Society can, and should, step in to protect the rights of one of its own, without abridging the rights of self-determination of the other. The situation, ex utero, has changed.

The judgment of the medical staff may now trump the mother. She doesn't determine viability. Expert opinion about viability carries tremendous weight. From where does the medical staff derive the moral authority to make life-and-death decisions? From society. We trust their presumably unbiased expertise. We trust their system of peer review. We trust them to do the right thing.

Just like "right to die" issues at the other end of life, things can get complicated. And, this is where the black-and-white nature of fundamentalist religious ideology can directly interfere with doing, or allowing to happen, that which is best. I would say that sound judgment, in these matters, should derive from the secular, from the real world, from the objectivity of scientific opinion.

Taking into account the wishes of the family, perceived viability, the best judgment of doctors, and, for the first time, the interests of the society in which the child is now a brand new member, a decision must be made about what is the best course of action. I would think that there would need to be very compelling reasons, in this horrible post-abortion-live-birth scenario, why heroic measures would not be made on the infant's behalf. It's a judgment call.

While the fetus exists under the jurisdiction of the mother's womb, especially prior to viability, her rights, her liberties, her health, her well-being, her right to control the fate of her beget, her right to control her own fate, should be the ultimate concerns of her society.

Her fetus is not a citizen. Granting it rights will, automatically, limit the rights of self-determination of the US citizen in whom's body it resides, upon whom it is dependent.

As a healthcare provider, you should be most concerned with the medical needs of the free and independent woman before you, assessing what help she requires, the steps that should be taken to protect her health, her safety.

You should be most concerned with safeguarding the well-being of your patient, up to and including providing her access to a safe, clean procedure, if that is her wish. You should care about helping her to avoid a situation where she feels compelled to go out and procure a wire hanger and a vacuum cleaner. You should care about helping her to avoid a situation where she ends up back in the ER with an altogether different life-changing crisis.

---"In any case, these late-term abortions are incredibly barbaric and I find it so hard to believe that people going into the medical profession could end up at a place where they'll literally snap the head off of a living 23 week old fetus in the process of an abortion - for a living."

You are projecting an awful lot of angst onto an action that, done quickly, would be relatively painless even on a being with a fully developed thalamus-cortex connection, let alone a 23 week old fetus which lacks this level of development. If you snuck up behind a 30 year old adult, and fully snapped his neck, he would have little or no time to feel pain, or even register what had happened. A fetus has nothing close to the level of awareness of a 30 year old adult. A fetus would have little to no awareness of what had happened to it.

Plus, you are serving up an awfully big serving of guilt and judgment onto a fellow doctor who is merely the best person with the best medical training to accomplish the woman's goal properly, safely, painlessly. He/she is providing help to someone in a life-changing moment, a frightening moment, to a person who may be desperate for that help. Possibly, someone young, scared, and alone. Someone making one of the most difficult decisions of her life.

Of course, I'm not talking about this "aggressive and violent" prostitute. I understand that she's bad. She's bad because she supports herself by doing perhaps the only thing that she feels she knows how to do. She's bad because she has sex, regularly, and with strangers. She's bad because she has an addiction, another situation with which a medical person might be able to help, if he's not to busy judging her unworthy.

If an abortion is to be performed, we should all hope that the result is assured. Snapping the spinal chord IN UTERO does the job. It prevents exactly the type of life-long suffering and impairment that is likely to be in store for the unwanted infant you describe.

An unwanted pregnancy, with prolonged crack exposure, followed by a botched abortion, followed by a living, profoundly premature infant with a host of severe problems --this is tragedy, compounded by tragedy, compounded by tragedy. Isn't it better that the mother's wishes of termination be fully and properly carried out? It is in no one's interest that society force her to gestate against her will. It is in no one's interest that this situation result in a highly-impaired, unwanted live birth.

I my opinion, a woman has a truly basic, inalienable right to self-determine, to request medical assistance with the removal of something unwanted, and life-changing, that is growing within her body.

---"I don't believe doctors should be in the business of killing. Elective late term abortions are blood curdling in their horror."

Again, this is an awful lot of breast-beating and hair-pulling for an objective medical professional.

My guess is that your blood would be less curdled if the procedure saved the life of the mother.

My guess is that your blood would be less curdled if the mother were part of a nice suburban couple who had just found out that their late-term fetus was suffering from spina bifida, or profound retardation, or severe craniofacial deformities.

My guess is that your blood would be less curdled if the mother were not a whore.

I understand that her totally irresponsible behavior must be very frustrating to you. But, do doctors only help people they deem "sinless"?

Sure, but there's a level of enthusiasm for their wellbeing which gets lost. If the patient doesn't care about their health, how much should I?

"Perhaps she was screaming that she "wanted it out" because she was in a stressful situation and she wanted it out! Wanting it out doesn't make her evil. She is allowed to "want it out.""

Who's saying she was evil? But a great deal of responsibility for this child's fate lies on her shoulders. I'm not saying she's a bad person for being a prostitute or using drugs - I'm saying she's a bad person for being totally irresponsible about her own fate as well as her child's. If she wanted an abortion, why'd she wait 6 months?

"My guess is that your blood would be less curdled if the procedure saved the life of the mother."

No - the procedure itself is horrible. When it's done for a good reason then it's more morally acceptable, but it's not less horrible.

"An unwanted pregnancy, with prolonged crack exposure, followed by a botched abortion, followed by a living, profoundly premature infant with a host of severe problems --this is tragedy, compounded by tragedy, compounded by tragedy. Isn't it better that the mother's wishes of termination be fully and properly carried out?"

No - if it actually was at 25+ weeks (which I believe it was) and the mother hadn't had any other emergent medical issues then the best course would indeed have been to force her to maintain the pregnancy and give birth at term.

"You should be most concerned with safeguarding the well-being of your patient, up to and including providing her access to a safe, clean procedure, if that is her wish. You should care about helping her to avoid a situation where she feels compelled to go out and procure a wire hanger and a vacuum cleaner."

Sure, I can help her by telling her she can give the baby up for adoption. Of course I would give all the information, but I needn't condone it or be a party to it's outcome.

"If an abortion is to be performed, we should all hope that the result is assured. Snapping the spinal chord IN UTERO does the job."

Sure, in theory, but would you so nonchalantly say the same thing about a 9 month fetus? Why can't the mother just wait a few weeks and give birth at term?

"I my opinion, a woman has a truly basic, inalienable right to self-determine, to request medical assistance with the removal of something unwanted, and life-changing, that is growing within her body."

---"there's a level of enthusiasm for their wellbeing which gets lost. If the patient doesn't care about their health, how much should I?"

I totally understand. Yet, you chose this career. It's not personal. This prostitute does not make foolish choices just to piss you off. We care about her objectively, as a fellow human who needs help.

---"I'm not saying she's a bad person for being a prostitute or using drugs - I'm saying she's a bad person for being totally irresponsible about her own fate as well as her child's. If she wanted an abortion, why'd she wait 6 months?"

Moral judgments make her less likely to seek help. A tendency to judge situations through the black-and-white morality of religion can be very distracting to you, and can drive away your patients. She is not bad. She is deeply challenged by her circumstances. I will grant you, they are circumstances of her own making.

Is it frustrating that she is being so foolish with her health? Absolutely! We try to educate her. We cannot force people to care for themselves (assuming they are in full possession of their faculties).

Is it frustrating that she is being so foolish with the health of her fetus? Absolutely! She may. There is no way to force someone to have prenatal care. She is the decision-maker. Is it frustrating to watch someone making foolish decisions? You bet! They are still her decisions to make. We offer advice, education, assistance.

Why'd she wait 6 months? 'Cuz she's a foolish person who is trying to survive in an extremely difficult world. She has no skills. She has a drug habit. She has a need to feed herself, clothe herself. She is possibly living on the street. She may be dealing with violence.

This situation is not a priority for her. It should be a priority for her, but it really isn't.

You and I have the luxury of being able to have wonderful discussions about morality on our very expensive computers. She's trying to survive. For someone who is starving, is the theft of bread an immoral act?

She should be told that her poor decisions have consequences. It should be explained to her that she has options. But, ultimately, she will lead the life of her own choosing. She has basic rights of self-determination. While the baby exists in her womb, he goes along for the ride.

---"No - the procedure itself is horrible. When it's done for a good reason then it's more morally acceptable, but it's not less horrible."

You are projecting your own feelings about pain and fear of death onto a being that does not experience life as you do.

From The New York Times:

"Mark Rosen was the anesthesiologist at the very first open fetal operation, performed in 1981 at the University of California, San Francisco, Medical Center, and the fetal anesthesia protocols he pioneered are now followed by his peers all over the world. Indeed, Rosen may have done more to prevent fetal pain than anyone else alive — except that he doesn’t believe that fetal pain exists. Research has persuaded him that before a point relatively late in pregnancy, the fetus is unable to perceive pain.

Rosen provides anesthesia for a number of other important reasons, he explains, including rendering the pregnant woman unconscious and preventing her uterus from contracting and setting off dangerous bleeding or early labor. Another purpose of anesthesia is to immobilize the fetus during surgery, and indeed, the drugs Rosen supplies to the pregnant woman do cross the placenta to reach the fetus. Relief of fetal pain, however, is not among his objectives. 'I have every reason to want to believe that the fetus feels pain, that I’ve been treating pain all these years,' says Rosen, who is intense and a bit prickly. 'But if you look at the evidence, it’s hard to conclude that that’s true.'

Rosen’s own hard look at the evidence came a few years ago, when he and a handful of other doctors at U.C.S.F. pulled together more than 2,000 articles from medical journals, weighing the accumulated evidence for and against fetal pain. They published the results in The Journal of the American Medical Association in 2005. 'Pain perception probably does not function before the third trimester,' concluded Rosen, the review’s senior author. The capacity to feel pain, he proposed, emerges around 29 to 30 weeks gestational age, or about two and a half months before a full-term baby is born. Before that time, he asserted, the fetus’s higher pain pathways are not yet fully developed and functional."

This is from an excellent article. You might really enjoy it. I don't know how to make a link, but I'm sure if you paste a few lines to Google, you will find it. The article is quite objective. It features other learned people who believe that pain might be felt earlier.

But, for a doctor to describe these procedures as "blood curdling in their horror" sounds like projection and/or religious propaganda.

---"Of course I would give all the information, but I needn't condone it or be a party to it's outcome."

True. If you are determined to bring your religion into this situation, you may. You have a right to self-determination, also.

One would hope that you would have the sophistication to recognize that, for every doctor who refuses her the treatment she chooses, the treatment for which she might be desperate, she ends up one step closer to it's unavailability, one step closer to the back-alley.

She's either entitled to this procedure, or she's not. If she is, then you are one of the finite (though plentiful) number of people with the training to accomplish it. You, too, may self-determine, but, if you do recognize her right, then withholding your expertise is disappointing.

---". . . would you so nonchalantly say the same thing about a 9 month fetus?"

" . . . Until when? 24 weeks? Why then?"

I would think that maternal requests for death of the fetus, at full-term, would be extremely uncommon. I understand that, rarely, some otherwise normal women kill their newborns, which shows just how desperate they can be. But, to look a doctor in the eye and request that a full-term fetus be killed . . . . does that ever happen? Surely, a woman in that situation knows that her baby can survive and be adopted. Regardless, as I said, doctors may self-determine, too. I would think it would be extremely difficult to find a doctor who would be willing to snap the spine of a healthy, full-term fetus.

I DO NOT believe that a woman has the right to demand that her fetus be KILLED.

I believe she has a right to request the evacuation of her uterus. She has a right to control her own body.

While the contents of her uterus are being removed, a doctor should proceed as he/she sees fit. A quick in utero fetal death might be the doctor's best choice. Perhaps the doctor feels the fetus should survive. Women should understand that, once the child has exited her womb, a living child has become a citizen. We are able to extend it rights, without trampling any of hers. Regardless of the wishes of the mother, the doctor may choose to try to save its life.

The morality of her request IS related to fetal awareness and ability to feel pain. Given our current understanding of how the brain works, the point where the thalamus connects with the cortex seems like a good estimation of when the fetus might start to feel pain. Yet, no one is guaranteed freedom from pain. Should we make forceps deliveries illegal, because there might be pain? Pain estimates make bad legal standards.

We have two sides to this equation, two people whose decisions will greatly effect the outcome. I am quite comfortable with the idea that most people experience a basic human instinct to do what is right.

On one side of the equation is the pregnant woman. I do not believe that we have any reason to think that women wish suffering on their unborn child, even those they intend to abort. They are not assumed to be psychopaths. They have valid reasons for what they wish to do. I believe they are in the best position to decide, for themselves, and for their unborn children, what is best.

You have come up with an extreme example, a woman who does not seem to care. She is deeply challenged by her circumstances. She is not demonstrating proper concern for herself, or her fetus. A very sad situation. I certainly don't believe that she should be parenting anyone. I believe that, if this woman chooses abortion, she should have access.

The other side of the equation is the doctor. Society makes certain assumptions about doctors. We have a basic trust in doctors. We trust them with life-and-death decisions. Yes, doctors profit from the procedures they do, but we believe that a doctor wishes to protect his/her own reputation. We believe that they will do what is best for their patients. We believe they will safeguard the public health.

If anyone is in a position to understand the most current wisdom about issues like viability, fetal drug exposure, fetal pain, etc., it is the doctor. The doctor has knowledge about the woman's situation and the health and development of the fetus. The healthier and more viable the fetus, the less the doctor is going to feel comfortable aborting it. He/she is in the best position to counsel and advise the mother. These situations should be evaluated on a case-by-case basis.

We believe that the woman's intentions are not based on malice.

We trust the doctor to do the right thing.

No matter what happens, I do not find the argument compelling that society has an interest in bringing charges. These issues should be sorted out between a woman and her doctor, not in the courts. Inserting the law into health care issues has a chilling effect. It drives people underground, away from the help they need.

Look at how unsuccessful the war on drugs has been. By making drugs illegal, you create a black market. By prosecuting people for their addictions, you turn people into criminals instead of getting them the help they need. Moral and legal judgments drive people away from health care.

Women should have access to safe-harbor places where the can leave their newborns without legal ramifications. They should understand that hurting a newborn is a crime against a fellow citizen.

Sometimes, the baby should be saved. Sometimes, not. Sometimes, a quick, assured death is best. If a doctor is going to snap the spine of a fetus, it must be done in utero. That is where the mother has the jurisdiction to grant him/her permission.

Ex utero, society's right to protect one of its new members takes precedence over the wishes of the mother, and unless there are highly compelling reasons, as decided by the medical staff, I would think that a living child should have heroic measures taken on its behalf.

"Moral judgments make her less likely to seek help. A tendency to judge situations through the black-and-white morality of religion can be very distracting to you, and can drive away your patients."

Why do you have to make everything a battle between religion and secularism? I'm not the one who brought up religious sources for ethics, nor would I even describe my ideas as black and white.

But the fact is that moral judgements are part and parcel of what doctors do and if you don't have a good sense of ethics before you start then you could end up in very strange places.

"Is it frustrating that she is being so foolish with the health of her fetus? Absolutely! She may. There is no way to force someone to have prenatal care."

Heh, well that's certainly open for debate. But while I'm not so quick to rush for legal consequences or forcing anything, it must be made clear that doing wrong by your unborn child is not a legitimate choice.

"You are projecting your own feelings about pain and fear of death onto a being that does not experience life as you do."

Actually I'm not. What the fetus experiences is not my issue here but rather the fact that one is gruesomely destroying a baby that could otherwise be viable! It's wretched. And I bet you'd agree if you ever saw one performed.

"One would hope that you would have the sophistication to recognize that, for every doctor who refuses her the treatment she chooses, the treatment for which she might be desperate, she ends up one step closer to it's unavailability, one step closer to the back-alley."

Or one step closer to not killing another human fetus at all.

"She's either entitled to this procedure, or she's not."

Oh, for that she is very clearly not. I don't believe that a right is something which one person can be entitled from another. One does not even have a right to medical care generally since that would necessarily mean the enslavement of the medical field. As a simple matter of fact though in America today she is granted the freedom to pursue that goal. That doesn't mean she is entitled to it.

"I DO NOT believe that a woman has the right to demand that her fetus be KILLED. I believe she has a right to request the evacuation of her uterus."

Sure, she has the right to request whatever she wants. That doesn't mean she's morally on the level and that doesn't mean she has a right to getting what she wants.

I fail to see how performing late abortions is somehow better for all the parties involved compared to the mom just waiting a few weeks and giving birth at term. Some women might go back alley but many more would likely put up with a few weeks more of discomfort. Why is abortion so preferred in this culture over adoption?

My value in balance here is not fetal pain but the value of human life. While fetuses are in many respects clearly not 'persons' yet, they are a clear potential and their lives are worth something. That value is the same in utero or ex utero.

First of all, let me apologize for making posts that are way to long. I think we have too many issues going on at once.

I am trying to point out the difference between what is moral and what is legal. They are, of course, not unrelated.

I fully embrace the idea that we all, especially doctors, must constantly refer to our obligations to BOTH sets of guidelines.

But, moral guidelines are much harder to pin down. In our very diverse, multicultural, multiethnic nation of many religions, we do NOT all agree on all issues of morality.

To make something ILLEGAL should require a much higher standard, a much more universally understood public reaction of "that's wrong", and a compelling reason that society has a universally understood interest in protecting itself by PUNISHING those of its members who cross the line.

I don't know where you get all that stuff about enslaving doctors. I think I was very clear that I believe that all of us have a right to control our own behavior, to self-determine. Each and every one of us will look within his or her own heart and decide what we feel is the correct course of action, the moral choice, in ANY situation. Short of that which is illegal, we may all act as we see fit.

Quite the opposite of enslaving doctors, I am saying that, while guided by their own moral principles, doctors should have greater LEGAL latitude. They hold a greater share of the public trust. Intrusion of the LAW into matters of health care, in binding doctor's hands, can have very negative effects on public health.

Again, look to the horrendous example of illegal drugs. Our prison system has been crippled by the explosion of people who have been made criminals by the so-called "war on drugs." Would society not be better served if they got some treatment?

Look to the example of right-to-die issues at the end of life. Do we all agree that patients in the final stages of horrifying illness should be denied medical assistance with their passing?

Particularly concerning health care, society had better have very compelling reasons to make something illegal. Making treatment options illegal drives the behavior of doctors and patients underground.

These are not people who are acting with malice against society. They have valid medical needs.

Patients have valid medical needs.

Doctors have valid reasons for feeling that they wish to help.

You are free judge all of these people as "bad" if you choose, but do you want society to step in and make them criminals?

Do you wish to chase them out of the safety and cleanliness of our public hospitals?

"To make something ILLEGAL should require a much higher standard, a much more universally understood public reaction of "that's wrong", and a compelling reason that society has a universally understood interest in protecting itself by PUNISHING those of its members who cross the line."

Yes, that's one point. But the other is that we live in a democratic society with different kinds of people living in different regions of our country. It may very well be that the people of one state will compellingly find that x kind of abortion is wrong while another will find just the opposite. What is a scandal of our whole legal system lies in creating rights where they never existed in the first place.

Another point is that the state needn't act through criminal means of 'punishment' per se, but through a wide series of civil acts which make it practically difficult or reverse incentives.

"I don't know where you get all that stuff about enslaving doctors."

It wasn't directed specifically at you, but the whole concept of 'entitlements.' Morally, how can the state entitle the work of one person to the ends of another? It's an obscenity on the concept of rights.

"Intrusion of the LAW into matters of health care, in binding doctor's hands, can have very negative effects on public health."

That may be true, but society in general has other interests than just the relative health of its citizens. Without doubt, abortion has negative effects on the health of fetuses. Given today's plentitude of contraceptive methods, if people took more forethought for themselves then abortion would be a much more rare event. Negligence - more than anything else - is the reason why there are unwanted pregnancies. Perhaps not making abortion so easily available on demand would encourage people to be more considerate for their actions?

"Particularly concerning health care, society had better have very compelling reasons to make something illegal. Making treatment options illegal drives the behavior of doctors and patients underground."

Like selling organs?

"These are not people who are acting with malice against society. They have valid medical needs."

Medical need? 99% of the time abortion is as medically necessary as a facelift. Maybe that should also be an entitlement.

"Do you wish to chase them out of the safety and cleanliness of our public hospitals?"

This isn't an either/or type of thing. Promote responsibility, promote contraception, promote the idea of adoption. These are all ways to reduce abortion rates as well as reduce back alley procedures.

Regarding Roe V. Wade. That's not the operative precedent. The controlling precedent in the US is Casey which allows states much more leeway about what legislation they can pass if there is a chance that the fetus is viable. Roe used trimester division while Casey used viability.

Very interesting! I wasn't familiar with the case so I looked it up on the official source (wikipedia) which states,

"The plurality recognized viability as the point at which the state interest in the life of the fetus outweighs the rights of the woman and abortion may be banned entirely "except where it is necessary, in appropriate medical judgment, for the preservation of the life or health of the mother"."

It seems one of my stated objections to Roe has already been assessed, agreed on by plurality of the Court - and is current precedent!

David's Harp "Musings on the jumbled interplay between emotions, ideas and beliefs"

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